US BANK SHIPPING FORM 5524
* required fields
  Pickup Location: Delivery Location:
Company Impact Technology
Address 1 State*: MN TX
Address 2  
Zip
 
City
State
Contact  
Main No.  
Fax No.  
Mobile No.  
Email *  
     
Company  
Address 1  
Address 2  
Zip
 
State
City
Contact  
Main No.  
Fax No.  
Mobile No.  
Email *  
(leave weight blank if you are not sure)
Make Model Serial Number Asset No. Lease/RE: No(s). Weight(lbs):
Pickup location type:
Residential Commercial Insurance Amount: $
Accessible to 53ft truck/trailer at pickup time? Yes No
Inside pickup? (select "no" if <100' from exit) Yes No
Stairs inside facility? If so how many (below): Yes No
If so how many inside:
COI required? (Certificate of Insurance): Yes No
Loading Facility (choose one)
  Freight Dock
Street Level Accessible
Unleveled or Stairs
* If "YES" for stairs tell us how many outside:
Notes:
   
Give 24hr pre-call info:
Contact with 24 hour notice at: ( E.g. Contact Contact Name with 24 hour notice at: Contact Phone number)

Open to Days (E.g. Open 8am to 5pm M-F)
I agree to the terms & conditions of this shipment.
A copy of this form will be sent to the “Bill to” party.